Dr. Chris Beyrer has spent his entire professional career, and much of his adult personal life, battling AIDS. As a medical student, he was at the forefront of treating Haitians in Brooklyn, while friends, and his lover, fell ill and died. Beyrer escaped infection -- for which he credits "absolutely religious" use of condoms -- and went on to help Thailand design and implement effective prevention programs, including one that showed "behavioral interventions" and condoms dramatically lowered infection rates in young Thai males. He is currently an associate professor at Johns Hopkins Bloomberg School of Public Health, and the director of the Johns Hopkins Fogarty AIDS International Training and Research Program. Here he talks about how Thailand became a rare success story in combating the sexual spread of AIDS, although the country's epidemic among drug users still rages on. He also describes how Burma is central to Asia's AIDS epidemic and why he believes that to successfully fight AIDS, countries need to invest their own resources and not just rely on outside funding. Beyrer worries of ever truly getting ahead of the disease. "For those of us who have watched this happen, to have the same conversation in 2000 with the minister of health that you had in 1995 in another country, and in 1985 with the Reagan administration, is a kind of terribly painful déjà vu. You just always hope that somebody for once is going to say, 'We're going to implement a prevention program right now because we don't have an epidemic, and let's see if we can avoid one,'" he says. This is an edited transcript of an interview conducted March 30, 2005.

… I walked onto the wards in 1985, into the unfolding epidemic in Brooklyn, which was really quite different from the unfolding epidemic in much of the rest of New York City. East Flatbush was a predominantly Haitian neighborhood; at that time, Brooklyn was the second largest Haitian city after Port-au-Prince. We were ahead of Miami at that point. It was already a mature, severe epidemic, and we had pediatric AIDS. I remember one of my first patients was a 73-year-old lady with Pneumocystis pneumonia, and of course this was when we were still pretty much doing clinical diagnosis; we weren't really sure how it was transmitted. I think it's fair to say that from the first day of my career, I had to stare this thing in the face. …

Tell me personally about your own experience of coming up against the problem.

Well, that period in the early '80s in New York City -- first of all, keep in mind it was scary for a lot of reasons, but certainly one of them is that it really wasn't clear how this thing was transmitted, so for health care workers there was a great deal of fear. For medical students, who are scared anyway, and should be scared, because they aren't very good yet with procedures, trying to learn how to do things -- take blood from patients, put in arterial lines, do spinal taps, learn all the physical skills of modern medicine and modern invasive medicine -- to be learning that in a context where a mistake could cost your life, added to what is already a stressful experience for anybody. We all were dealing with that, and we all dealt with needle sticks. Remember, this is before AZT [zidovudine], so there really wasn't anything you could do if you had a needle stick or you had an exposure. There were a lot of late-night phone calls, and there certainly were some people both in med school and nursing school and others that I knew who just decided that this wasn't the right field for them because it was too stressful.

At a more personal level, I had been living abroad. I came home to the States to go to medical school and started a relationship with a wonderful man who was an actor and who had been living in New York City all through the AIDS [crisis]. At that time, before the HIV test, we really didn't know much about asymptomatic infection, and it looked like a clinical disease. Then when we did have the HIV test, it was clear that most people walking around with HIV infection in fact were healthy, and many of those were gay men who lived in New York City, like myself and my partner.

It was an extremely frightening time in addition, and eventually what transpired was that I was living in a discordant relationship, as it was called at the time: One of us was positive, the other not. We endeavored to keep that that way, but about half the gay men in New York City roughly were HIV positive by the time we had a test and before there were any guidelines about what was safe and what was not safe.

Within a very short time, I was taking care of people with AIDS at work; I had a partner who was dying at home; and most of our friends were ill. Actually, from that time in my life, there is one other person that I came out with who survived. It was an all-consuming, extraordinary thing.

[Tell the story about when the test came out. What did you and your partner decide to do?]

When the HIV test came out, my partner and I debated what to do, and whether or not it made sense to get tested since there really wasn't any treatment. I think that for many people at risk at that time, that it was a big, big discussion. We decided not to get tested and instead just to really be very, very monogamous, committed to each other and extremely safe and be absolutely religious about condom use.

To this day, I know that I am alive and sitting here talking to you because condoms are so effective in HIV prevention. It's something that now condoms are under threat, but they really do work. Eventually what happened was, my partner began to have symptoms, and at that point we decided we couldn't delay any longer, and he indeed had AIDS, and I was still negative, happily.

Then began something that I think everybody who's a health care provider at some point in their life has to deal with, which is that you end up on the other side of the fence, and you are one of the family members waiting in the hallway to find out what's going to happen. It's a very sobering experience for sure, and a very humbling one. You have to struggle, and particularly as a young physician as I was -- my partner survived through my medical school internship and residency and died just as I finished my training -- you're not that experienced; you're not that senior a person; and it's not so easy to back off and not try and be a doctor and really just be a partner. But he helped with that.

How did that experience influence your next steps?

… Patients need a physician who is going to be behind them 1,000 percent and supportive, and I was in the process of saying goodbye a lot, and that was not helpful, I think, to anybody. I actually stopped working for a while. I took leave, and I wasn't sure what I was going to do next.

I had done public health training here at [Johns] Hopkins, and I'd been very involved in vaccines, and I had the feeling that an HIV vaccine was maybe one of the only ways out of this, just because of the history of other viral epidemics, that they'd gotten controlled by vaccines. I actually had a call from a friend, who was the Maryland state AIDS coordinator, saying, "Hopkins got this grant to start setting up the infrastructure for HIV vaccine trials in Thailand, and they need somebody who can move to Asia in the next couple of weeks, because the money's there, but there's nothing on the ground. Would you be interested?"

It was literally about six weeks later I arrived in Chiang Mai, in 1992, just as that epidemic was really reaching its most severe point. I started really focusing not so much on treatment, but really on prevention and prevention research, and had the extraordinary good fortune to be in a place where the government at the time was open to scientific data. They were remarkably responsive to the findings of our research, so it actually felt as though one was having a real impact.

One of the first things I did there was write the safe-sex protocol for the Thai army HIV prevention program, which was based on what our focus group data from soldiers had suggested, work that was done by some colleagues here, which was that it had to be sex-positive. It had to be oriented toward male bonding, because the real risk behavior, which was visiting brothels and paying for commercial sex services, was something that guys did together as a group, and that that part of it was just about as important as the sexual experience for many of them. It had to, of course, be focused on condoms and early detection and treatment of sexually transmitted diseases.

Over the years, we've launched a now very well-known prevention trial that really showed that behavioral interventions and condoms could dramatically reduce the rate of new infection in young, poorly educated, Asian, heterosexual men. That's a tough audience; it's a very tough group of people to get to amend their sexual behavior and practice safer sex. We were able to do it and show declines in infection.

Talk about the history of AIDS in Thailand a little bit. Basically, the first cases were diagnosed around 1986.

That's right. That's the early period in the region, but certainly in Thailand, most of the cases were either Thai men who had sex with Western men, either in the U.S. or Britain, or gay Thais who had Western partners. There were also some hemophiliac cases, and those were seen globally. That was true in many countries, because of the way the pooled [clotting] factor worked. In many of those settings, those early cases did not appear to play a role in subsequent epidemics; they were sort of early cases that were quite self-limited.

In the Thai situation, there's something else [that] happened, which was that there were a scattering of cases, and then there was a very abrupt outbreak with an extremely high rate of infection. That really got going in 1988 in the Bangkok prisons.

It turns out this also is the way subsequent epidemics have occurred in Iran and several other settings. Prisons can play a special kind of role in the sense that if risk behavior is going on, it's happening in a closed space where people can't really protect themselves. In the Thai prison setting, first of all, drugs are available, and there is often a lot of exchange between prisoners and guards of drugs and money and so forth. But generally speaking, safe injection equipment is not [exchanged]. You have people who are using, and you have a great deal of needle sharing and a lot of making of handmade injection equipment that is very unsafe, obviously.

Secondly, of course, there's consensual or nonconsensual homosexual sex in prison settings in many countries. Generally speaking, there has not been a great deal of condom access there. That's true in Thailand, and it's unfortunately true in the U.S., and it's true in many other settings. We're still 20 years on fighting the fight of getting condom access for prisoners.

Why is that hard?

Condom distribution in prisons is resisted in many settings by many governments -- even though it's a part of, for example, the World Health Organization's best practices and guidelines for prevention -- because many governments perceive that it is in a sense condoning sexual behavior in prison or even promoting it, facilitating it, and somehow it's an admission that sexual behavior occurs in prison when, generally speaking, it's forbidden. This is an old argument. In the places where it's actually been done and looked at, generally speaking, there isn't any evidence that it promotes the behavior, but there certainly is evidence that it reduces the risks associated. ...

What we know from Thailand is that clearly prison is an extraordinarily high-risk time. The rate of infection among injection drug users goes up an order of magnitude during the time that they're in prison; that was a study that was done by the Bangkok Metropolitan Authority and the CDC [Centers for Disease Control and Prevention]. The difference is roughly 3 percent per year of injectors on the outside will become HIV positive, and 30 per 100 persons [per year], or 30 percent per year, of injectors will become infected during the time they're in prison. Virtually all of that is due to the fact that there's no drug treatment in the prisons, there's no access to clean injection equipment, and there's still no access to condoms.

So you put people who are at risk in an incarcerated setting, and you deny them any prevention tools. That's a recipe for an epidemic, and that's actually how the Thai epidemic got going. In 1987, 1988, there was an amnesty and a mass prison release, and six months after that the HIV infection rate in injection drug users across the country went from 2 percent to 40 percent in a very, very short time. ... Unfortunately it has continued over many years. HIV rates have never really come down in injection drug users in Thailand, and prevention services for drug users have lagged.

But that was not really the outbreak which led to the wider Thai epidemic. When things really changed in Thailand was when … HIV began to appear among women in the sex industry -- and that is not because of tourism or because of international sex trade, but really because use of sex workers was such a normative behavior for young Thai men, was such a common and widely practiced behavior. … That was by 1989, 1990 or so. The proportion of young men who used sex workers was very high; at that time, the condom-use rates were very low.

Thailand had a political crisis during that time, where there had been a quite corrupt civilian government, the government of Chatichai Choonhavan, which had a lot of interest, for example, with the tourist industry and the hotel industry, and Thailand was being marketed as an international destination. They were worried that public disclosure of the HIV epidemic, and particularly that there was HIV in the sex industry, was going to undermine tourism. So Thailand gets very high marks for cleaning up its blood supply early -- did that years before most other countries in Asia; for humane treatment of people with HIV -- also got that going early on; but not in this prevention arena at that point.

In 1992 there was a military takeover of that civilian government, which actually was quite popular at the time, and there was a relatively brief stable period, and then the head of military … declared himself prime minister, and there were riots, and a number of people were killed.

At that point, the constitutional monarchy intervened happily to restore democracy, and a transitional government was put in power, and that was the government of Anand Panyarachun, who was an academic and a highly respected civil society figure. He brought in the medical and public health communities, and abruptly -- I mean, literally within 72 hours or so -- ended the denial and said, "OK, what should we do?" At that point, Khun Mechai Viravaidya [Editor's note: "Khun" is a term of respect in Thailand], who is a famous family planning advocate and a promoter of condoms, who had really helped lead Thailand's demographic changes to a modern population structure with low fertility [rates], he became an adviser on AIDS and began this famous 100 Percent Condom Campaign.

It was dramatic. On the one hand, there was a national mobilization around AIDS. It suddenly was everywhere -- in the media, in billboards and in schools. There was a real responsiveness to the public health evidence. There was, of course, a tremendous increase in condom availability and distribution. The numbers went up every year. It reached very quickly about 60 million free condoms a year being distributed by the government, and targeting really the commercial sex [industry], which had been the driver of the epidemic. …

[Are brothels legal or illegal?]

It's important to keep in mind that Thailand outlawed prostitution in 1960, so all these venues are illegal. So this was really a pragmatic public health approach. Rather than spend a lot of time debating whether or not prostitution would be legalized ... they simply said, "OK, we're not going to try to crack down on this." There were several exceptions to that. One was anywhere that was employing sex workers under age 18 -- that was held to a very different standard, as I think everyone would agree it should be; secondly, that the access to public health people needed to be there, and condoms needed to be there.

I think it's fair to say that the area where this got least enforced, unfortunately, was those places that were really employing a lot of illegal aliens and migrant sex workers, principally from Burma. Over time, what has happened to the sex industry is that fewer and fewer Thai women have been willing to work in it; fewer and fewer Thai families have been willing to let their daughters work in it or even to sell them, as sometimes happened in the past. That demand has been filled by Burmese women, women from China, in some cases by women from Laos. … The people coming into that industry now tend to be tribal minorities who don't speak mainstream languages and are from even more remote places, where the news about the virus still hasn't been heard.

Can you describe the 100 Percent Condom Campaign and what some of those billboards looked like?

The 100 Percent Condom Campaign had a famous set of logos that actually went on every sex venue, so you'd see it over the door when you went into the karaoke or the pub or the massage parlor, which said, "No condom, no service, no refund": You have to use a condom, and if you don't, you can't have sex here, and we're not giving you your money back.

But it was broader than that. You will hear a rhetoric in public health about multisectoral responses and that you should bring in many sectors of society, the schools for example, [which is] actually a difficult thing to do in practice. But in Thailand it really did happen, so that, for example, the schools got involved in condom education, condom promotion, and they would have school competition days with condom competitions -- who can put on a condom the fastest and have it still be appropriate, and who knows the five ways that you can get HIV and the five ways that you can't. It went all the way down to secondary school. Now, if we could do that in the United States, we'd be a different country, but we can't. But the Thais were certainly able to do that.

A big part of the 100 Percent Condom Campaign was upgrading clinic services, clinics for sex workers, STD clinics; getting condoms out away from doctors' offices and out into venues where they're actually used, so getting them out into bars, distributing free condoms in places where people buy alcohol. ...

Another component of it was a greater investment in surveillance. Thailand still has some of the best data we have on risk groups, and over the years we were able to see that the rate was coming down in soldiers; now very solidly the rate has come down in pregnant women; that there were consistent declines in STD patients. Indeed, the one population where we have not seen declines over time is in injection drug users. But in many countries you try and understand what's happening from the data. …

In Thailand it really is incontrovertible. We have very solid evidence. I think that the fact that surveillance data was generated by the Ministry of Public Health of the country in collaboration with the U.S. CDC, who helped on technical support, but nevertheless it was Thai data, had an impact on decision makers, and at a policy level that is just so important. It can't be overemphasized how important that is, because in so many other settings, people don't pay attention to the evidence, and they end up sort of either copying a program that doesn't relate to their epidemic, which obviously is not going to work, or being rather ideological about what's right and what's wrong for their culture and not having a response that comes out of what's actually going on.

What we've seen in many other settings is that ideology is trumping science repeatedly, and that is always painful.

What was it that allowed the Thai leadership to, as early as 1986, set up that surveillance system? And what did they do?

I would say that one of the reasons that Thailand has mounted such a vigorous response and such an early response is partly that it's a country with a strong academic tradition. There are a number of good medical schools; there have been, over the years, a lot of investment in academia and civil society. You really had indigenous people who could step up to the plate and lead.

Secondly, there's a long-standing tradition of public health. ... That relationship between the medical scientific public health community and villages, communities, towns, cities, is a shared sense of trying to do the right thing. …

It probably also didn't hurt that the royal family, which is so highly revered, had been responsible for the introduction of Western medicine to Thailand, and subsequently of modern public health. The father of the current king did a Master's of Public Health in Hopkins in 1911 and is widely perceived to be the father of modern medicine in Thailand.

When we were working on the army campaign, the monarchy stepped up and said, "The number one enemy of our army is HIV, and it is a patriotic duty to protect yourself and your military buddies from this infection, because it's the most likely risk of death." It just allowed a public space in which anything that had evidence for prevention we could put forward.

If you were to think of a polar opposite of that, of a country that rejected Western medicine, that had a vacuum of leadership, what would you say it was?

Certainly in the region I would say the early response to HIV spread in Burma was terrible. It generally was denial. There has never been a great deal of support for academia and medical research, but since 1990, when the current junta took power, they've closed down the universities repeatedly; they have harassed the intelligentsia; they have driven out most of the professional class; they destroyed the public health infrastructure in the middle of an epidemic. It's hard to argue that that wasn't the worst move you could make. In 2004, just as a contrast, if you look at the proportion of dollars that the Thai government is putting into AIDS, of its own money compared to donor dollars, it's about 94 percent Thai and 6 percent donors'.

In contrast, just the British aid agency has put about $15 million into HIV/AIDS in Burma, and the national budget for a country of 48 million people in 2004 was $22,000. Now, that is not a response; that is a crime against humanity. That's all it is.

Unfortunately, we have seen that in a number of other settings. I think the [President Thabo] Mbeki position [in South Africa], that HIV is not the cause of AIDS, will in the future be seen as one of those positions that undermined an evidence-based response and led to countless deaths. ...

Then there are some others that are a little bit different. There are a number of African governments that were willing to take some donor aid but were just so unwilling to go through any kind of government reform that they have undermined the response.

What are you thinking of?

Zimbabwe, under [President Robert] Mugabe, a country that actually 10 years ago looked quite good in terms of things like STD care and condom promotion and clinical capacity. In this last decade of misrule, that system has essentially collapsed. There haven't been antibiotics in the public health clinics in 10 months in Zimbabwe; you can't even get penicillin for syphilis. That is not what to do in the middle of an AIDS epidemic.

When Ethiopia engaged in its disastrous and extremely bloody border war with Eritrea, again in the middle of the HIV epidemic, they lost their donor aid because both countries were caught diverting money for poverty alleviation and health care to the war effort. ...

[Under] the [Gen. Sani] Abacha regime, the five-year military dictatorship in Nigeria, essentially everything stopped -- scientific, public heath, HIV/AIDS, civil society -- and that was what has been called, I think quite aptly by the British political thinker Timothy Garton Ash, [a] kleptocracy, when the government in power is there to steal the resources of the country. There are a number of those, and they always do very badly in any kind of public heath undertaking, particularly HIV/AIDS.

[What was Burma's role in Asia's epidemic?]

One of the tragedies of Burma has been its isolation and its closed nature in terms of scientific exchange, information, media and so forth. It's always been difficult to understand what's going on there, and the regional implications. But nevertheless, by 1995, when it was clear that Asia was indeed having the second worst epidemic after Africa, the province of China with the highest HIV rate by far was Yunnan. In fact, in those early 1990s years, about 85 percent of all the cases in China were clustered in three little districts on the border with Burma.

On the other side, the northeast of India had by far the highest HIV rates in all of India, and that is one of the most remote and closed places, specifically Manipur State, which to this day has the highest HIV rate of any Indian state. It's closed; it's an insurgent area; it's been under Indian security laws for a number of years. ...

It was very clear that in India and China both, the highest HIV rates in those two enormous countries were on their Burma border, and ditto northern Thailand, which had 10 times worse [an] epidemic than the rest of Thailand. So the centrality of Burma to that epidemic was clear.

Now, at the time, if you looked at global opium poppy cultivation, Burma was the largest single producer of opium poppy, and it was the world's largest producer by far of heroin. ... Burma was very central because of its narcotics-exporting economy.

But it turns out that it was also very central for other reasons, and that has a lot to do with its own epidemic of HIV. The northern part of the country, the northeast, in particular Shan State, is where virtually all the heroin production is in the country. But the north of the country is where there are a series of very large mines, jade and ruby mines, and these are, as a lot of developing country mines are, open pit mines. They look like huge anthills. In the rainy season, it's entirely impossible to work there, so you go down to about 5,000 people. But in the dry season, once the ground is dry enough to dig, 200,000 to 300,000 people come from all over Burma to work. Of course there's a great deal of commercial sex coming up there, but more importantly a great deal of injection drug use.

We've got good interviews that document that people are offered either money or heroin in exchange for their labor. And because the kyat, the Burmese currency, was so worthless, people actually use heroin as a medium of exchange. You can buy guns with it; you can buy gems with it; you can trade things that are actually valuable, as opposed to the kyat. That resulted in a terrible epidemic in Burma, and we conservatively estimated in 2001 that about one in 29 adults in that country was HIV positive, which made it probably second only to Cambodia as the worst epidemic in the region.

But there was yet another nuance to this, which is that, because it is at the center of these connections between China, India and Thailand, and because of the way that drugs are injected there and used, there was a great deal of viral mixing. So it has turned out to be a place that has generated a series of new recombinant viruses.

Those viruses have subsequently become the predominant epidemic viruses, for example, in China, in northeast India. Just to tell you about how that might happen, the old IV bags, they used to have a drop stop inside them so you could see the drops coming down. One of the ways that heroin is used in the mines is that the drug is put into the IV bag, and then you can buy drops -- you can buy five drops or 10 drops from the bag. But the infusion equipment is reused 30, 40 times. We have, again, very well-documented cases of, for example, a needle being so dull from going in so many people's arms that somebody's sitting outside sharpening it with a nail file. That is not what you want to do in the middle of an HIV epidemic.

You can imagine, of course, how many people's blood ends up in an IV bag like that and what the likelihood of viral mixing, both within the population and within the equipment, is going to be. ...

[What were the results of the 100 Percent Condom Campaign?]

... The evidence is with [the] 100 Percent Condom Campaign that once it really got launched, the use of commercial sex workers, in fact, declined; condom use went up, and the number of the risky behaviors went down.

That is because, for a substantial proportion of people, once they understand what the HIV risks are, they're unwilling to take them. So what we've seen -- and the 100 Percent Condom Campaign has some of the best data for this -- is that instead of promoting promiscuity, what you're promoting is responsible sexual behavior, and actually the amount of promiscuity goes down a bit. That turns out to have important implications for prevention.

Now, of course, people will argue that condoms can lessen the consequences, like unwanted pregnancy, for adolescents or for other groups. That is true. That is absolutely true. But it's also true that, for example, the promotion of abstinence, which has been looked at in a number of other settings, has a relatively modest increase in the amount of abstinence and a consequent increase in the amount of STDs and unwanted pregnancies. The net effect is almost nothing, and that is because if people know less, they're more vulnerable. So condom promotion has got to go along with frank, evidence-based sexual health education. …

What would you say to these people who say it's immoral to give out condoms? What is the balance of the considerations?

I would say, just in the most straightforward way possible, we have to deal with reality, because, for example, promotion of condoms does in fact decrease promiscuity. That's what the data shows, and not the converse. Nobody has an interest in promoting unsafe sexual behavior or unwanted sexual behavior or early sexual behavior in adolescents, all those things we know also have negative health consequences. But there isn't any evidence that making sex safe means there's going to be more sex.

The same is true, for example, with harm reduction for injection drug use. People argue that if you give needles to addicts and take dirty needles away, you're condoning drug use. Well, what's the data? The data show, consistently, that first of all, you begin to build bridges to injectors; you get them in to treatment. You can begin to talk about helping people get off drugs, what services are out there, what access there is. You build a relationship because you're saying to people, "I care about your health; I'm trying to protect you." Then you start to really be able to engage people. Where needle and syringe exchanges have been established -- New York City is a great example -- blood-borne infections overall -- HIV, hepatitis C and the others -- are dramatically decreased. ...

The fundamental reality is that none of the risk groups for HIV infection can be walled off or separated from the larger population. What we're seeing, for example, in Thailand is that now, 2005, the failure to address the epidemic in drug users has meant that Thailand continues to have more and more new infections. …

But let us be clear: This is an issue that is much less relevant for sub-Saharan Africa, which really is a heterosexual epidemic. But it is absolutely at the center of what we're calling the next wave of AIDS: Russia, Central Asia, the five Central Asian Republics [Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan], Iran, Pakistan, Indonesia, the Caucasus, the Balkans, Estonia, Eastern Europe, this enormous area, where, if you look carefully, the great majority of infections are due to injection drug use. …

What's your projection for that next wave?

I think we're already losing the fight. I think there are some glimmers of hope. China is certainly one. ... But virtually across the region, what you have is demonstration projects and pilot projects and projects funded by small NGOs [non-governmental organizations]. Very few of them are to scale, not taken to the scale that's required to deal with national epidemic. So I think that bodes poorly.

Secondly, of course, there is a lot more information than there was 10 years ago or 20 years ago, and there's a great deal more money, but there are restrictions on that money. Now we're in this awful, painful situation where there's finally the money commensurate to deal with the worst pandemic of modern times, and the strings attached mean we're going to lose another round of this war. …

[What's your assessment of the George W. Bush administration?]

There's no question, if you look just at straight dollars, that the current President Bush has put more money into global AIDS than any of his predecessors, and it is substantial money. He has really pushed for it. It's not been a passive effort; he really has been engaged. I think that the focus on treatment, and the moral obligation for treatment, is important and has had a real impact for people on the ground, or it has the potential to.

On the other hand, treatment is treatment, and you can't confuse it with responding to HIV spread. HIV spread is something else entirely. And as we know, for the most part, HIV spread is driven by people who are recently infected, healthy, asymptomatic, and very unlikely to show up anywhere where there's treatment. There is a disconnect there, but it's just difficult to deal with.

If you look in terms of HIV spread, then we're facing a disastrous legacy, because the string attached to the treatment dollars is limiting evidence-based prevention, is limiting family planning access, has really tied up the anti-abortion position of the conservatives in the U.S. with HIV prevention in such a way as to make our partners unable to respond. Nobody's talking here about supporting or not supporting abortion; we're simply talking about trying to engage with those organizations on the ground in hard-hit countries that do HIV prevention and that also, generally speaking, do family planning. It's not like there are so many services in Africa that you can choose which ones you're going to support and which ones you're not.

The latest target has been harm reduction, so the U.S. is going to every one of the international forum[s] and is actually making quite a bit of headway in forcing international organizations, if they want U.S. dollars, to back off the evidence for prevention in drug users. UNAIDS [Joint United Nations Programme on HIV/AIDS] was the most recent one to fall. They have just backed away from supporting harm reduction; they're taking it out of their language of best practices. At this point I think it's fair to say that only two international organizations have even tried to withstand the Bush administration pressure. And I should say it's not just the Bush administration; it's Congress. ...

But those two organizations that have withstood this are the International Committee of the Red Cross and Red Crescent Societies, which have embraced harm reduction as a part of the promotion of human dignity, ... and the second is the WHO [World Health Organization], which came out with a very strong endorsement in saying the WHO is a professional technical organization, and we are not going to back away from the science, and if the science says that harm reduction, needle and syringe exchange and methadone maintenance are effective tools for HIV prevention, we're not changing. ... It's absolutely great that WHO has stood up as a scientific and technical organization and it's not going to back away from the evidence, not going to back away from harm reduction. But they are not the implementers of the Global Fund [To Fight AIDS, Tuberculosis and Malaria], and that's where the U.N. dollars really aren't flowing. So they actually have less programmatic impact, unfortunately. ...

… It cannot be underestimated how important it is for national governments to take responsibility and use their own dollars. They don't have to be rich, and they don't have to put in a substantial proportion of money, but they have to use their own money, their own resources, their own people, and make a commitment to this problem.

If it's just donor-driven, however well intentioned or wherever the money is coming from, it doesn't have the same impact; it's not sustainable. Those countries like Thailand, Senegal and Brazil that have [put] substantial resources of their own into the epidemic have had the best outcomes, both in prevention and in care. So that's critical, and it is particularly important for the kind of middle-income countries like India, China and Russia, which really do have the resources to respond and which in many cases have just shamefully underfunded this.

There is a role for private philanthropy, and probably the most important role is to fund those demonstration projects, feasibility projects, that can show the way forward and that can support, for example, civil society and community-based groups, community-based organizations who are doing innovative work and who are really on the ground in touch with organizations. But if those kinds of demonstration feasibility projects are going to work, they have to be taken to scale, and to take them to scale, they really need to engage governments and the international bodies that work at that level.

In the case of Brazil, there's no question that the World Bank investments in things like harm reduction, in prevention for men who have sex with men in the prisons, which were very politically unpopular with a series of Brazilian governments, ensured that Brazil really did have an effective response. If you look in 1990 at the HIV rate in South Africa at a population level and in Brazil, they were virtually identical. They both were at about 1 percent prevalence.

Brazil is now at well under 1 percent -- it's about 0.6 percent of the population, so six per 1,000 -- and South Africa is approaching 300 per 1,000. That is a failure of prevention; that is a national disaster and, the evidence would suggest, at least partially a preventable one. …

Is AIDS a preventable pandemic or not?

HIV epidemics are preventable. We know that; we have very good evidence for how preventable they are. But what you need to prevent them -- and we have a tool kit that is sufficient to do that -- is an educated population, a government that's open to scientific evidence, an early and evidence-based response, and implementation of the complete tool kit: condoms, STD care, drug treatment and needles and syringe exchanges for drug users, blood screening.

None of those things are terribly expensive; for the most part, they're all relatively simple. This is a virus that's not very efficiently transmitted. Heterosexual transmission of HIV is actually very inefficient compared to most other sexually transmitted diseases. Nevertheless, what we see again and again is, it's very hard to implement the basic took kit.

Communities and governments both are reluctant until the virus has already spread and the cat is out of the bag to respond, and by the time you can get a debate going and get funding and get programs going, generally we're about a decade late. For those of us who have watched this happen, to have the same conversation in 2000 with the minister of health that you had in 1995 in another country, and in 1985 with the Reagan administration, is a kind of terribly painful déjà vu. You just always hope that somebody for once is going to say, "We're going to implement a prevention program right now because we don't have an epidemic, and let's see if we can avoid one."